Building Bridges Inc.

Deficiency cited, provisional status inspection

1) Participants #1-#5 record did not have an inventory of belongings completed at admission. 2) Participant #5’s file did not contain written documentation that an orientation to the program was completed within 24 hours of admission. P#5’s intake date was 7/14/24 with orientation form not dated by either the participant or staff performing the orientation.

Deficiency cited, provisional status inspection

1) Participant #1’s record did not have written documentation that an ICPC agreement was completed prior to placement. P#1’s intake date was 5/7/24 with no document on file.

Deficiency cited, provisional status inspection

1) Participant #1-#5’s treatment plans and treatment plan reviews do not contain the following information: a. The physical and medical needs of the participant; b. An educational plan; and c. A discharge plan with an anticipated date of discharge;

Deficiency cited, provisional status inspection

1) The following treatment plans were not updated every 90 days as required: a. Participant #1 treatment plan dated 5/17/24 with the next review occurring on 10/21/24; b. Participant #4 treatment plan dated 6/11/24 with the next review occurring on 10/30/24; and c. Participant #5 treatment plan dated 7/15/24 with the next review occurring on 10/30/24.

Deficiency cited, provisional status inspection

1) The program did not have written documentation that the parent/guardian or participant had input into the development or review of the following plans: a. Participant #1’s plans dated 5/17/24 and 10/21/24; b. Participant #3’s plan dated 11/5/24; c. Participant #4’s plans dated 4/30/24, 6/11/24 and 10/30/24; and d. Participant #5’s 7/15/24 and 10/30/24.

Deficiency cited, provisional status inspection

the surveyors review of records, interviews, and on-site inspection.

Deficiency cited, provisional status inspection

1) The program is currently using physical discipline as a punishment for behavior. The program has the participants

Deficiency cited, provisional status inspection

1) Participants #1, #2, #3, and #5’s record did not contain documentation that the program reviewed the participant rights and grievance procedure with the parent/guardian, the participant, and the program at admission.

Deficiency cited, provisional status inspection

the surveyors review of personnel records.

Deficiency cited, provisional status inspection

1)Staff #3 did not have a completed background check prior to working at the program. Staff #3’s hire date was 10/14/24 with the background check results received on 10/23/24.

Deficiency cited, provisional status inspection

the surveyors review of records and on-site inspection.

Deficiency cited, provisional status inspection

1) The program did not have written documentation of fire drill being conducted on a quarterly basis for each shift. The program currently has two separate shifts and is missing the following: a. Quarter #1 is missing a fire drill for the overnight shift; b. Quarter #2 is missing a fire drill for the overnight shift; c. Quarter #3 is missing a fire drill for the afternoon shift; and d. Quarter #4 is missing a fire drill for the overnight shift.

Deficiency cited, provisional status inspection

1) Staff #3 did not have a written documentation that a 24-hour orientation was provided to staff prior to working with participants. Staff #3’s orientation documentation was not dated by new staff or staff performing the orientation.

Deficiency cited, provisional status inspection

1) Staff #1 and #2’s de-escalation training and working with participants training was expired. Staff #1’s de-escalation training expiration date of 4/12/24 and Staff #2 had a training expiration date of 4/5/24.

Deficiency cited, provisional status inspection

1) Participants #1, #2, #3, and #5’s record did not contain documentation that the program reviewed the participant search procedure with the parent/guardian and participant at admission.